Impact of the Public Health Reforms

Transcription

1 Impact of the Public Health Reforms Linda Marks Senior Research Fellow Durham University Centre for Public Policy & Health

2 Commissioning Public Health Services: the impact of the health reforms on access, health inequalities and innovation in service provision Research team: Linda Marks (PI), David Hunter, Shelina Visram, Llinos Jehu, (Durham University); Anne Mason, Dan Liu (University of York); Howard Davis (Coventry University); Joanne Smithson (Voluntary Organisations Network North East). Project administrator: Lisa Monkhouse Funding: Department of Health Policy Research Programme ( ) Disclaimer This presentation is independent research commissioned and funded by the Department of Health Policy Research Programme (Commissioning public health services: the impact of the health reforms on access, health inequalities and innovation in service provision, PR-R ). The views expressed are those of the authors and not necessarily those of the Department of Health.

3 New Responsibilities Three inter-related work streams: i) The ring-fenced public health budget: deployment over time and variation in spend and outcomes ii) Commissioning preventive services: innovation in provision, design and targeting of selected preventive services iii) The public health leadership role of local authorities

4 Methods Four national surveys Analysis of spend and outcomes data Ten case study sites reflecting geographical spread, political control, levels of disadvantage and including two-tier authorities 111 interviews in case study sites Documentary analysis

5 Advantages and Disadvantages Advantages Influence over wider determinants of health Closeness to communities Innovation in commissioning Procurement processes Tempered by Bad timing, given financial stringency in local authorities Concerns over sustainability of the public health profession Fragmentation in commissioning

6 Results Part 1 Work stream findings Part 2 Future impact of reforms

7 PART 1 Centre for Public Policy & Health

8 Public Health Budget Impact of in-year and ongoing cuts Benefits (or not) of the ring fence Views of mandated and non-mandated services Public health budget as catalyst

9 Impact of Cuts Reducing and targeting lifestyle services Prioritising strategic development rather than commissioning Negotiating reductions in existing contracts Staff reductions Continued re-badging of services in line with local authority priorities

10 We have used some of the money to basically protect some other cuts that were going to take place in the organisation around things that have a health input public health is less safe funding-wise with the local authority than it is in the health service, because of the scale of our cuts. (Elected Member) A lot of the things that we would normally do we have reclassified, I think legitimately, as public health activity. (Chief Executive) What s happened is people have got into quite narrow debates around the technical efficiency of where you spend the public health budgets; does it work, does it bring these outcomes, but the real debate is around allocative efficiency within the whole of public services investment. (DPH)

11 Ring fence and Mandated Services Ring fence Useful in transition and promotes accountability Permeable but affords some protection Totality of resource is more important Aligned with priorities of the local authority Mandated services Different views over what should be included Minimum levels of provision need clarification Mandatory or statutory?

12 But if we don't have a ring fence and we don't have mandatory, I would fear for public health services, I think, generally. (DPH ) The list of mandated services is not particularly helpful as it is not determined by any specific prioritisation process. Smoking cessation for example, is not a mandated service but would rate as one of the most cost-effective public health interventions available. (DPH)

13 Public Health Budget as Catalyst Service delivery agreements across directorates Leveraging funds from CCGs Supporting the VCSE sector Public health skills development National funding

14 A New Culture of Commissioning Preventive services re-commissioned and re-modelled Local authority procurement processes are applied Social and community aspects are emphasised Greater engagement and co-design Integration with local authority services

15 So moving public health out of PCT and putting it into a local authority has changed the culture of commissioning. So our local authority has tendered several services, and has awarded them to non-usual bodies, including the private sector. So that s been a shift, a different cultural shift and there s lots of learning from that so far. (CCG) That s what the NHS does not do. It does not engage its users in an active discussion about where it can get efficiencies out of the system. It just doesn t do it. (DPH)

16 Innovation in Commissioning Synergy Increased community involvement and co-production Community wellbeing: less emphasis on single interventions Public health on a wider stage

17 How can we put added value into what the council is already doing, with a public health hat on? So I think that is the innovation and it's happening everywhere across the council to a greater or lesser extent. (DPH) It s a general understanding over time here that if you re going to find creative solutions to some of the issues we ve got, the answers aren t in the town hall are they?. We need to work with people in order to get them. (CE)

18 Public Health Leadership Public health challenges Systems leadership Corporate ownership of the public health agenda Developing the public health role of Members Health and health inequalities impact assessment Influencing and networking skills of public health Integration of public health perspectives

19 So you either as a council say what we re interested in is the money, not really the public health responsibilities. Or the council says we now have a series of brand new responsibilities as a council, and we re going to make sure we deliver them, and we need money to do that. And I think that depends on therefore the attitude of the council. (DPH) So I think when we re talking about the whole system, the whole council is thinking that public health is our responsibility. That s where responsibility and outcomes come back to every portfolio holder. (HWB Chair) So it's how do you see the health inequalities challenge as a whole council challenge and a whole community challenge? That would be the hallmark of good public health leadership. Perhaps just stop calling it public health. (DASC)

20 Future of the Public Health Profession Local authorities are less amenable to senior specialist roles Staff reductions and problems of capacity and sustainability Integration and potential loss of professional identity Emphasis on data analysis, needs assessment and targeting More evidence for influence in people directorates Importance of political credibility, networking and negotiating skills

21 I m not sure what difference it makes that a public health director within a local authority needs to be making a statement on an annual basis. I don t know what good it does or how much notice is taken of it. (HWB Chair) Given at least 80% of the public health grant is now actually managed by other directors here in {x}... and more than half the staff are now managed elsewhere, there's an existential threat to the public health function in local authorities. (DPH) I think the other disadvantage is that over time it's quite likely that public health practitioners will become local authority officers and you'll lose the clinical governance and the clinical input, potentially. I think that will happen. (DASC)

22 Governance and Accountability The role of Health Scrutiny Committees Involvement across the range of Executive Members Variation in extent to which public health is embedded across decision-making structures

23 PART TWO Centre for Public Policy & Health

24 Future Impact From commissioning public health services to influencing and advocacy across the system Alignment with local authority priorities Factors influencing decision-making for public health

25 Commissioning for Public Health Less focus on lifestyle services Strategic and advocacy role Community wellbeing across the place

26 So it could be that as time goes on we focus less on commissioning of services, and much more about capacity building, influencing and our leadership role. (DPH) I am much more sanguine about the disinvestment in traditional commissioned services, and the reallocation of that resource to protect other parts of the council, other council services which will have an enormous short-term impact on health and wellbeing if they were cut. It feels I can live with that now. (DPH Phase 2) The real question to a director of public health I think now is not, what are you doing with your public health budget, but, how are you influencing what the public sector commissions on your place -based footprint... to reframe, what is public health commissioning, to ask, what is the commissioning of public health? (DPH) Centre for Public Policy & Health

27 Alignment with Local Authority Priorities Statutory responsibilities Managing demand Admission to hospital Flow through the front door of social care Number of children being taken into care Giving children the best start in life

28 Within a council, adult care is the reason why councils are about to go bust....so there s been some reorientation of public health resources to better address my front door. (DASS) Ignore the pot hole issue, if you look purely at children s and adults social care, increased looked after children, increased child protection, increased referrals, aging population in terms of demand management around adults and children s social care. I don t think we re going to be able to afford to do anything else other than our statutory duty. (DCS)

29 Factors influencing decision-making State intervention and individual responsibility Evidence, cost-effectiveness and return on investment Concepts of prevention and wellbeing

30 We had a workshop for elected members about the budget in the future and somebody said well everyone knows they shouldn t smoke so I don t see any reason at all why we should spend any money on stop smoking services. (DPH) How do we make sure that the public health budget fits in with that overall commissioning intention of the council, which is to do what we can to prevent children from being harmed, to prevent adults being vulnerable and lonely and all of that and citizens feeling safe. (Service Director)

31 I think one of the problems that we ve got with local authorities and elected members, in particular, is that they do not have a very high regard for evidence. Whether that s evidence of need, which they think they understand because... they know that community, or evidence of what is effective, because that s just not something that crosses their radar most of the time. (DPH) The worst thing anyone could do as a director of public health is move into a council and be all the expert, because that is not how councils operate. (DPH) We ve got to do something different. So define that in public health. I think what we tend to do, what tends to hamper innovation generally, and I don t know whether this is more or less a public health matter, is our desire in the health system to be evidence-based. But you can t get the evidence without innovating. (CCG)

32 Impact of the Reforms Reframing: public health roles; health inequalities; prevention; evidence Alignment: across public health priorities and local authority priorities Re-commissioning: social models, co-design and new providers Integration: health, social care and wellbeing, children s services Timing: impact influenced by financial stringency: a lost opportunity

33 Questions Raised What are core public health activities in the new context? What is the critical mass and skill set required? What are minimum requirements for preventive services? How much variation is acceptable? How can the role of Elected Members be enhanced? How can scrutiny of performance be further developed? Impact of future reductions on public health services?

34 Acknowledgements The research team would like to thank all ten case study sites for agreeing to participate in this research and, in particular, interviewees and survey respondents who generously gave their time. The team would also like to thank Kate Melvin for her contribution to case study fieldwork and analysis and Michelle Cook and Lisa Monkhouse for support in research administration. We would also like to express our appreciation to members of our External Advisory Group, David Pye (Chair), Professor Peter Kelly, Gerard Crofton-Martin, Bev Wears and Rob Bellingham for their helpful comments and support throughout.